Utilization Review RN (Remote - Compact/AZ RN License)

Change Healthcare

Kansas City Kansas

United States

Healthcare - Nursing
(No Timezone Provided)

The position is primarily accountable for performing initial clinical appropriateness review of requests for services that require prior authorization or retrospective review. The review process is performed in accordance with established Client (health plan) protocols/guidelines, benefits, and clinical appropriateness criteria. This position works closely with the Health Services Manager and the Medical Director to evaluate, monitor and assure the appropriateness and medical necessity of selected care for members as it relates to quality, continuity and cost effectiveness. This position works with non-clinical staff as part of the referral and/or authorization process. This position is responsible for managing utilization and, if necessary, discussing utilization of service and standards of patient management.

What will be my duties and responsibilities in this job?

  • Performs initial, concurrent, and/or retrospective review of services that require prior authorization or medical appropriateness review using health plan benefits, clinical appropriateness criteria, or plan guidelines/protocols.
  • Documents clinical appropriateness reviews and care management activities in managed care operating Systems.
  • Facilitates cost effective and quality patient care by effective communication with physicians, providers and members.
  • Maintains knowledge of regulatory requirements (i.e. URAC), and state utilization review standards.
  • Ensures authorized services are performed in the most cost effective appropriate setting.
  • Coordinate discharge planning activities for inpatient level of care services and facilitate referral to care management programs.
  • Participates in case review and/or team meetings with managerial team and Medical Director.
  • Participates in rotational after-hours coverage.

    • What are the requirements needed for this position?

  • Minimum of 3-5 years of clinical experience
  • One year of care management, utilization management experience, clinical documentation or clinical auditing experience
  • Successful work history in a clinical setting and/or health insurance environment
  • Required: Registered Nurse with an active nursing license to practice in the state of the contracted Client (single state AZ RN license OR a multi-state/compact RN license)
  • Preferred: Bachelor’s Degree in Nursing

    • What other skills/experience would be helpful to have?

  • Knowledge of medical appropriateness criteria such as InterQual®, Milliman Care Guidelines®, or eviCore healthcare.
  • Knowledge of CPT, ICD-10, and/or HCPCS codes or coding experience.
  • Knowledge of precertification and/or medical review processes in a health care payor or third-party environment.
  • Knowledge of URAC or NCQA standards.

    • What are the working conditions and physical requirements of this job?

  • Office/Home Environment.
  • Office Hours: 10am – 6:30pm CST Monday – Friday.
  • After Hours Rotation.

    • Join our team today where we are creating a better coordinated, increasingly collaborative, and more efficient healthcare system!

    COVID Mandate

    As a federal contractor, Change Healthcare is adhering to the Executive Order which mandates vaccination. As such, we are requiring all U.S. new hires and employees to show proof of being fully vaccinated for COVID-19 or receive an approved accommodation by their date of hire, as a condition of employment. 

    As we continue to navigate the ever-changing COVID-19 pandemic, we remain committed to doing our part to ensure the health, safety, and well-being of our team members and our communities. Proof of vaccination or accommodations requests will be collected once an offer is accepted with Change Healthcare. All accommodation requests will be carefully considered but are not guaranteed to be approved. 

    Utilization Review RN (Remote - Compact/AZ RN License)

    Change Healthcare

    Kansas City Kansas

    United States

    Healthcare - Nursing

    (No Timezone Provided)

    The position is primarily accountable for performing initial clinical appropriateness review of requests for services that require prior authorization or retrospective review. The review process is performed in accordance with established Client (health plan) protocols/guidelines, benefits, and clinical appropriateness criteria. This position works closely with the Health Services Manager and the Medical Director to evaluate, monitor and assure the appropriateness and medical necessity of selected care for members as it relates to quality, continuity and cost effectiveness. This position works with non-clinical staff as part of the referral and/or authorization process. This position is responsible for managing utilization and, if necessary, discussing utilization of service and standards of patient management.

    What will be my duties and responsibilities in this job?

  • Performs initial, concurrent, and/or retrospective review of services that require prior authorization or medical appropriateness review using health plan benefits, clinical appropriateness criteria, or plan guidelines/protocols.
  • Documents clinical appropriateness reviews and care management activities in managed care operating Systems.
  • Facilitates cost effective and quality patient care by effective communication with physicians, providers and members.
  • Maintains knowledge of regulatory requirements (i.e. URAC), and state utilization review standards.
  • Ensures authorized services are performed in the most cost effective appropriate setting.
  • Coordinate discharge planning activities for inpatient level of care services and facilitate referral to care management programs.
  • Participates in case review and/or team meetings with managerial team and Medical Director.
  • Participates in rotational after-hours coverage.

    • What are the requirements needed for this position?

  • Minimum of 3-5 years of clinical experience
  • One year of care management, utilization management experience, clinical documentation or clinical auditing experience
  • Successful work history in a clinical setting and/or health insurance environment
  • Required: Registered Nurse with an active nursing license to practice in the state of the contracted Client (single state AZ RN license OR a multi-state/compact RN license)
  • Preferred: Bachelor’s Degree in Nursing

    • What other skills/experience would be helpful to have?

  • Knowledge of medical appropriateness criteria such as InterQual®, Milliman Care Guidelines®, or eviCore healthcare.
  • Knowledge of CPT, ICD-10, and/or HCPCS codes or coding experience.
  • Knowledge of precertification and/or medical review processes in a health care payor or third-party environment.
  • Knowledge of URAC or NCQA standards.

    • What are the working conditions and physical requirements of this job?

  • Office/Home Environment.
  • Office Hours: 10am – 6:30pm CST Monday – Friday.
  • After Hours Rotation.

    • Join our team today where we are creating a better coordinated, increasingly collaborative, and more efficient healthcare system!

    COVID Mandate

    As a federal contractor, Change Healthcare is adhering to the Executive Order which mandates vaccination. As such, we are requiring all U.S. new hires and employees to show proof of being fully vaccinated for COVID-19 or receive an approved accommodation by their date of hire, as a condition of employment. 

    As we continue to navigate the ever-changing COVID-19 pandemic, we remain committed to doing our part to ensure the health, safety, and well-being of our team members and our communities. Proof of vaccination or accommodations requests will be collected once an offer is accepted with Change Healthcare. All accommodation requests will be carefully considered but are not guaranteed to be approved. 

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